Cleaning cannulated devices takes time, patience, elbow grease and a bit of know-how. Whether it's residual soil that remains in the lumens or lumens that are so small and long that it's almost impossible to run a cleaning brush through them, channeled and cannulated surgical instruments are a challenge to reprocess. Here's a collection of tips on how to do the job right.

1. Pre-treat devices. Cleaning should start before instruments hit sterile processing. Flush and soak cannulated devices as soon as possible so that blood, body fluid, bone and bioburden don't have a chance to accumulate and solidify in the instrument's cracks, crevices and hinges, says Charles Rosecrans, MA, RN, of the Madison (Ala.) Surgery Center. At FHN in Freeport, Ill., OR staff send instruments to sterile processing in a basin of water so that debris doesn't dry in the cannula, says Suzanne Dornink, RN, CNOR, BA-HCA, the service line director for surgical services. At the Virginia Eye Institute Surgery Center in Richmond, Va., cannulated items are flushed on the sterile field, placed in an ultrasonic cleaner and then flushed again with distilled water, says Lisa Sizemore, RN, BSN, CNOR, the director of surgical services. OR staff at the Tucson (Ariz.) Orthopaedic Surgery Center insert a probe into the cannulated instrument at the end of the case to prevent material from drying. Sterile processing staff then remove the probe before decontaminating the instruments, says Executive Director Stuart Katz, FACHE, MBA, CASC.

2. Flush before you sterilize. Many facilities hook cannulated devices to an ultrasonic cleaner that automatically flushes the lumens. "Once removed from the sonic, we run the instruments through the instrument washer," says Tracy B. Humphreys, BS, MS, CRCST, central sterile manager at Metro Health Hospital in Wyoming, Mich. Be sure to remove gross soil from instruments before processing in the ultrasonic cleaner, says Donna Nucci, RN, BSN, CIC, an infection control consultant and nurse for Yale New Haven Hospital's ambulatory services division. "Heavy soil can inhibit the cleaning activity," she says.

3. Soak in enzyme. Soaking cannulated instruments in an enzyme solution facilitates the removal of contaminants inside the instruments, says Ms. Nucci. "Enzymatic solutions break down protein matter and prevent blood and protein-based materials from drying in and on instrumentation," she says.

4. Use elbow grease. Clean all cannulations and hollow spaces manually, says Ms. Nucci. "It is imperative that you properly carry out manual cleaning, brushing and rinsing steps according to specific guidelines with each use," she says. "Shortcuts and lack of staff training may lead to protein debris left in cannulas and lumens to harden and lead to formation of biofilm on the surgical instrument."

5. Sterilize in a pre-vac cycle. After running cannulated instruments through a washer, techs at Madison (Ala.) Surgery Center sterilize the instruments in a pre-vac cycle "to ensure that the steam permeates the cannula," says Mr. Rosecrans. "They are sterilized using a pre-vac cycle even if a quick turnaround is necessary. No exceptions."

6. Use the right brush to navigate the channel. The right-sized brush to reach the full depth of the area is indispensable. "You can never have too many brushes," says Ms. Dornink. Her favorite? A tapered "Christmas-tree" brush that's small at the top and larger at the bottom. Experts say you should scrub inside cannulas or holes with a tight-fitting brush using a twisting action. Researchers in the Nov-ember 2009 issue of Sports Health: A Multidisciplinary Approach blamed an infection breakout in ACL reconstruction patients on a lack of small-enough wire brushes to clean a cannulated hex driver.

7. Validate that instruments are cleaned. How do you validate that a laparoscopic device that's engineered without a way for you to visualize the channel is clean? At Metro Health Hospital, a central sterile tech runs a clean nylon bristle brush or pipe cleaner through the lumens to ensure that the cannula is clean, says Ms. Humphreys. Techs also flush the cannula with distilled water to be sure that the water runs out cleanly. A good way to know that you've removed all the blood from the lumens is to push hydrogen peroxide through the instrument. Hydrogen peroxide will foam if any blood is left in, says Ms. Dornink.

You can also use test strips. Noting that "manual cleaning is a learned skill and subject to human error," AORN recommends that you use protein indicators to validate the cleanliness of cannulated medical devices. For example, there's a $1 dipstick test that consists of 3 pads that change color if soil residuals are found in the collected water that you flush through the channel.

8. Reach out to device manufacturers. You can't place flexible endoscopes, fiber-optic light cables and some rigid endoscopes in the ultrasonic cleaner, as the vibrations can damage them, says Ms. Nucci. Similarly, you can't expose delicate fiber-optic, microsurgery and lensed devices to ultrasonic cleaning, automatic cleaning or harsh chemicals. Device manufacturers' recommendations may require that you manually clean these instruments. Ms. Nucci suggests that you make a list of all lumened and cannulated instrumentation in use at your facility (including those that could be brought in by a vendor or are on loan) and ask the manufacturers to provide specific decontamination and sterilization guidelines.

9. Follow all the steps. Doing the job right means taking the time to follow all of the steps in cleaning, says Mary Wood, RN, BBA, director of the Hutchinson (Kans.) Ambulatory Surgery Center. Her facility soaks cannulated devices immediately in a enzymatic detergent to prevent debris from drying or accumulating and then hand-washes using a small brush. Techs then blow pressurized air through the cannula, followed by an ultrasonic 10-minute wash with low-suds detergent. Lastly, techs load instruments into a washer-sterilizer for a 20-minute cycle. Before processing, techs examine the instruments. Evaluate how well your staff manually cleans new instruments, says Ms. Nucci.